Pulmonology Prior Authorization and Denial Guide
Sleep study prior authorization pathways, CPAP and BiPAP compliance requirements, pulmonary function test bundling rules, bronchoscopy coverage criteria, and LDCT lung cancer screening eligibility, grounded in CMS NCD 240.4 for CPAP, AASM Clinical Practice Parameters, and major payer coverage determination guidelines for pulmonary services.
Sleep study and CPAP: home sleep apnea testing (HSAT, CPT 95800–95806) has replaced in-lab PSG as the first-line sleep apnea diagnostic for most commercial payers for patients without significant comorbidities. Most payers require HSAT before PSG unless the patient has comorbid conditions (COPD, heart failure, neuromuscular disease) that make HSAT unreliable. CPAP (CPT E0601) requires prior authorization and documentation of AHI ≥15 on HSAT or PSG, or AHI ≥5 with symptoms. The 90-day compliance check is required by Medicare and most commercial payers — CPAP coverage is terminated for patients who do not use the device for at least 4 hours per night on 70% of nights in any 30-day period during the first 90 days.
Biologic therapy for severe asthma: mepolizumab, benralizumab, dupilumab, and tezepelumab require prior authorization with documentation of severe eosinophilic asthma (eosinophil count ≥150–300 cells/μL depending on agent), two or more exacerbations requiring systemic corticosteroids in the prior year, and failure of high-dose ICS/LABA. LDCT lung cancer screening (CPT 71250 with modifier -LG) is covered by Medicare and most commercial payers for patients aged 50–80 with a 20 pack-year smoking history who currently smoke or quit within the past 15 years — consistent with USPSTF 2021 recommendations.